If ACA is repealed and Congress can’t agree on a replacement, what then?

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Welcome back and hope you had a good 4th of July. I will not repeat my usual obnoxious habit of explaining every July that the date the Continental Congress voted to declare independence from Britain was actually July 2. But, if you missed the other umpteen times I wrote that piece, here’s one of the old versions. Of slightly less historical import but making news while MinnPost was down for the holiday …

…With all humility and a willing acknowledgement that I can’t see the future: For the moment, I decline to take the suddenly-slightly-fashionable scarey/stupid “repeal-now-replace-later” approach to the Republican health care dilemma seriously.

Idea floated on Fox

Sen. Ben Sasse, R-Nebraska, seems to have brought this idea back for the current round of discussion, but he controls roughly 1 percent of the votes in roughly one of the houses of roughly one of the three branches of the federal government. He floated the idea on “Fox & Friends” on Friday morning and, 18 minutes after he ran it up the Foxy flagpole, President Trump (I’m guessing he was watching the show) tweeted:

“if Republican senators are unable to pass what they are working on now, they should immediately REPEAL, and then REPLACE at a later date.”

It is truly frightening to think a remark by one senator on a morning news show is the basis for a change in presidential position on a subject of this magnitude. Because I am hung up on such things, I must point out that Trump very explicitly rejected the repeal-now-replace-later idea on Nov. 11 on “60 Minutes,” dismissing it as stupid and not-gonna-happen. As far as I can tell, he has not explained when or how it got smarter, but one gathers there’s only so much brilliance you can fit in a tweet.

Sasse suggested a one-year-later effective date for the repeal so the House and the Senate and the president can spend that year coming up with the replacement plan (neither the specifics nor the broad outlines of which are known at this time, but rest assured, it’s gonna be great).

But neither Sasse nor Trump has given an answer that I can find to this question:

If you pass the repeal bill, and aren’t able to agree on a replace bill (and how can anyone possibly feel confident that they will agree on one), what happens then?

Replaced by nothing?

In such a not-so-very-unlikely case, presumably the Affordable Care Act – which, for all its assets and liabilities, has cut roughly in half the portion of the non-elderly population that was uninsured before the ACA passed in 2010 – just goes away and is replaced by nothing.

The Congressional Budget Office estimated recently that number of Americans without insurance in 2026 would rise by 23 million under the House version of Trump/Ryan care, and by 22 million under the Senate bill now under consideration. Those estimates were bad enough, but more recently and with a bit less notice, the CBO estimated that spending on Medicaid – the chief federal health care program for the poor and near-poor – would be 35 percent lower in 2036 under the supposedly more moderate Senate version of the bill than under current law.

Sasse and Trump seem to want to assure us that that would not happen. Why? Because, of course, if the Republican-controlled Congress passed a law putting Obamacare on a one-year sentence to oblivion, the same members who cannot agree on a replacement plan now would be able to agree on one then.

Because why?

Or, to put it another way, what if they don’t?

You could convince me that they would feel under even more pressure to come up with a new plan. And you could make a sort-of non-reassuring argument that it might work. But I haven’t heard Sasse nor Trump nor anyone else identified with this new plan-to-have-a-new-plan-then-that-we-can’t-come-up-with-now explain why the plan is guaranteed to work and the bill to pass or discuss what happens if it doesn’t.

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Veteran journalist Eric Black writes Eric Black Ink for MinnPost. His latest award is from the Society of Professional Journalists, which in May 2017 announced he'd won the national Sigma Delta Chi Award for online column writing.

Comments (19)

It’s pretty clear, isn’t it.
The Republicans get what they’ve wanted since the ACA was enacted: a return to the preACA situation where the lower classes couldn’t afford adequate insurance, and there was money available to give tax breaks to the rich.
It’s obvious to me the repeal would not be followed by any replacement beyond a fig leaf as long as the GOP controlled the government.

“Repeal and replace” is a very recent formulation. It always was “repeal” before that.

“Ending Medicaid” was something that young Paul Ryan fantasized about–and so did many other conservative Republicans in office now.

The AHCA (House bill) was premised on 2 more bills to follow to patch the leaks–whoever thought that would get buy-in by anyone thinks the “repeal now–replace later” is a valid promise.

Trump is no more informed on health-care and impacts on the population that he was 6 months ago. To a “deal-maker”, any deal that doesn’t end up in a net loss to him personally is an OK deal. Trading away other-peoples cards (and lives) means nothing

The “crash” method of governing is a crude attempt to get buy-in from the Democrats–get their finger-prints on the steering wheel.

And, the “moderate Republicans” have always caved with minor promises from the leadership.

On those grounds, a straight repeal on a “nuclear option” Senate is a possibility, but not a probability. The confusion of Medicaid and Obamacare provides good cover for dismantling a big portion of Medicaid, whereas two separate bills –one to kill Obamacare and the other to kill Medicaid–is too naked for Republicans who want to return to office.

…in part because of the way the ACA was passed. It seems very likely to remain so in the current political environment. So when the Democrats are back in power, they’ll seek to wreck whatever the GOP might pass this time around. Each of the parties have failed the public interest.

An unstable health Care system is so damaging to the public interest, it is only the voters who can fix it. The currently elected Senators and Representatives feel they must answer to narrow interests, not the public as a whole, so they will have to be compelled – by the voters, but also by the insurance industry and business in general, who also have a fundamental interest in a stable health Care system.

Only a general uprising – by all these parties – against partisanship applied to health care – will do. Until then, it will remain a political football.

They remain popular in an enduring way for more than 50 years. Why ? They are so clearly in the public interest, that’s why.

The GOP is painting itself into a very bad corner with it’s scheming and chicanery in a system so fundamentally popular with the majority of Americans. In spite of any temporary victory they may spin, no matter how they proceed from this point, there will be hell to pay. It just might end up getting us the single payer system we all deserve. In the end, their ideological intransigence might be doing us all a big favor.

This seems like a plausible outcome. The effective date of the repeal will be a year after the bill is passed, and can be extended, kicking the need to come up with a palatable replacement yet further down the road. In the meantime, Congress gets to take credit for “repealing Obamacare.”

Seventy plus times over roughly an 8-year period the Republicans have tried to repeal the ACA, with zero success. They voted in the House several times before they came up with a bill that would leave 23,000,000 people without healthcare – appalling. Then on to the Senate. They voted to leave 22,000,000 without healthcare, but couldn’t get it passed. They set a date of having it passed by last Friday, they failed. Per the President, “Who knew it was this complicated”? Answer: everyone but the Republicans. If they had an answer to the repeal mantra they won with, wouldn’t you think they would have had a grand plan already to go on day one, as Trump stated. Essentially what has happened is the Republicans have trapped themselves and they don’t know how to get out of the trap – they set. Campaigning based on outrageous statements has consequences as the Republicans are finding out. Now they have the philosophy of repeal now and replace later. If they can’t get it done now why could they get it done later? Being foolishly hung up on one word – REPEAL – is keeping them from accomplishing any of their stated goals like accomplishing the tax system overhaul, approval of a federal budget, setting debit ceiling limit, entitlement reform, etc.

Republicans are very willing to mess with people’s lives who hang in the balance of their decisions. The Republicans think it is okay if those with a preexisting condition don’t know if they will have coverage or not. It is okay with Republicans if people don’t know if they will be able to afford their life saving medicine or not. It is okay with Republicans if people don’t know it they will be able to have their next meal or not. It is okay with Republicans if people don’t know if they will be able to afford their insurance premium or not. It is NOT okay the Republicans are foolishly hung up on one word – REPEAL – while many wait for answers that are critical their lives. If you are waiting for Republicans to help you, it won’t happen. If you are not wealthy you just are not on the Republican’s priority list – get over it. Keep it up Republicans there may be a big REPEAL in the next election, all based on your accomplishments.

…my thanks to Neal Rovick. In a corporatized system focused on profit rather than health, we should not be surprised that the usual lapdogs for the well-to-do are simply playing their role. What might happen? We’ll go back to what we had before the ACA, meaning we’ll return to the situation that prompted the ACA in the first place, but, just as was the case before the current law was passed, profit will continue to come before health, and Republicans will pretend they have no blood on their hands when people die for lack of affordable health care.

Will be a nice big tax cut and when the replace part comes around later we will be surprisingly short of resources to enable any kind of broad coverage.

Healthcare is now joining education in the GOP defying gravity item list. Want a nicer house?: spend more money, want a better car?: spend more money, want a grander vacation?: spend more money.

In almost all aspects of human endeavor we find a positive correlation with expending resources and improved results. Except of course in public education and now healthcare. In these areas of endeavor spending less produces better results in the GOP handbook.

We live under a consensus based government. We never had government health care in this country not because it didn’t have support, but because we could never reach a consensus as to what it should be. Through an election miracle, for a brief moment in our history, unlikely to be repeated again in my lifetime we did have a consensus in Congress that could enact a form of government health. albeit one heavily influenced by political as opposed to policy considerations. Now we are exploring the irony of our political system. Just as it took a consensus to enact health care, it also takes a consensus to repeal it. And as it turns out, a consensus to repeal health care is just as difficult, bordering on the impossible really, as a consensus to pass it.

For decades now consensus has played a decreasingly significant role in policy, a fact that “centrist” or “third way” democrats have refused to recognize. Policy gets made by votes, you have the votes, you make the policy. You don’t have the votes, you watch the other guys make policy. Democrats had the votes to pass the ACA, now we’ll see if Republicans can muster the votes to replace it, consensus is irrelevant.

The reason we never had the votes to create a decent health care system is because those who actually control and influence our policy have never wanted a decent health system, they just wanted a profitable health care system. Neoliberal mentalities assume that a profitable system and a decent system must be more or less the same thing, hence Obamacare and it’s failure. Not that the ACA didn’t improve the situation, but it tinkered around the edges without striking at the heart of the problem, whether it survives or not, it won’t give us universal coverage, and it won’t control costs.

Sure policy should be organized around evidence-based consensus, but when you have one party of two parties in a system that doesn’t believe in evidence, and the other party is willing to give magic a try on the off chance that it might work… you get what we got.

Wreck the economics of healthcare in the US and not only do millions suffer preventable illness, death and bankruptcy, but the wealthy of the country who depend on high incomes from healthcare employment and investments take a huge hit. This will create the kind of financial disaster that makes the tech and housing bubbles seem like an afternoon in the park. Ready for a world wide depression? Repeal without a smart alternative, something Republicans lack the will or intelligence to create, and make it happen.

I was making a long drive through the night and came across on the radio a discussion led by a person whose entire life had been the study of healthcare delivery from a non-partisan point of view. They laid out the pros and cons of other countries approaches, what would fit in our country and what wouldn’t.

The healthcare problem is eminently solvable by smart people working for the best solution. Of course that will never happen because that requires putting our trust in non-influential, non-partisan experts instead of the ignorant politicians, lobbyists and political hacks that direct all of the activities of our government.

We have been worried about all of this for our current clients on Medicare. Although the ACA plans don’t interfere with Medicare, the bill had some funding included that came from the Medicare Advantage program. If they repeal the ACA, what happens to that funding? We had hundreds of questions like these with the first go round of ACA, which we addressed here:

I’m not the only one to make this observation but it’s basic one that everyone seem to keep forgetting: Republicans never recognized the fact that we have/had a health care crises in the first place, and they have completely disconnected themselves from the “reality based community”.

Kafka would be impressed. We have a situation wherein “centrist” democrats pulled an old Republican model for a better health market off the shelf and implemented it. (Before it was Obamacare it was Hillarycare, and before that is was an Heritage Foundation proposal). And on top of that you have a clear majority of magical thinking Republicans who are so ignorant they don’t even realize that their own system is already in place. Republicans really didn’t realize how complicated health care is, they have not coherent concept of health care, and no coherent context for discussion other than hatred for Obama.

So two things happened when Republicans tried to repeal and replace: 1) They found out that voters don’t actually want Obamacare to go away. 2) They discovered that Obamacare is by and large what they would replace Obamacare with. All they can do is trim around the edges, play with things like individual mandates and abortion spending, but an outright repeal is absurd.

So now we’ll find out which group of reality challenged republican’s can muster the most votes. Will it be the one’s who realize on some level that harming voters might cost them elections? Or will the those who want to return to the magical days of profit that never needed to be “fixed” in the first place.

Either way, Republicans are probably screwed. They’ll never actually figure out a way to “improve” Obamacare because THAT would a basic understanding of health care for which they have neither the inclination or intellect. If they simply repeal it (which is something only those with no inclination or intellect for understanding health would do) they’ll deliver death, pain, suffering, and financial catastrophe to millions of will-be voters.

Smart Republicans would simply move a few deck chairs around and claim to have made huge and substantial changes. Republicans aren’t tied to any particular notion of integrity to begin with so exaggerating the scope of their legislation is second nature anyways. Having declared their mission accomplished they could then move on to the next agenda items and blame any lingering complaints on the remaining vestiges of Obamacare to be addressed at a later date. Problem is that Republicans simply aren’t intelligent enough to pull such a scenario off, it’s putting a dogs in a room full of musical instruments and expecting a symphony orchestra to emerge.

Although I’m not an attorney, it seems very unlikely that repealing the ACA could be considered to be “reconciliation”, which the Republicans are using so that they can pass their mythical replacement with a simple majority rather than the 60-vote supermajority. The Byrd Rule states that a supermajority is required for any bill that changes policy, not just budget. The Republicans are walking a thin line already, but it seems likely that repealing a bill would be a major policy change.

The Byrd Rule is a rule, not a law. The Republicans could set it aside, if they wanted to. However, they know that they won’t always have a majority in the Senate and, when they’re back in the minority, they’ll want the Byrd Rule intact.

I also don’t see the Senate moderates supporting outright appeal. They aren’t a malleable as their colleagues in the House. And Mitch can only lose 2.

take one big step back from single payer. When Obamacare upped the poverty level to 4x your states poverty line, it was a way to get more folks on Federal assisted healthcare. The GOP doesn’t have the guts to call it like it is and put in a system that encourages able bodies folks to work and buy their own health insurance. Our healthcare system being run by those folks in DC (both parties) is a disaster waiting to happen. Like most idealistic plans, single payer Govt run healthcare, sounds good but paying for it and more importantly running it will be much harder than talking about it!

Kicking it back to the states in a desperate attempt to avoid the inevitable will only deliver unnecessary suffering and death upon millions of Americans. Red states in particular lack the resources and/or the competence to provide affordable universal healthy care. Even wealthy red states like Florida and Texas are so horribly mismanaged that they’ll just cut more taxes and services and brag about how much smaller their government is. Conversely other States will be forced to raise taxes to make up for the federal funding cuts, thus raising the cost of health care rather than lowering it. Large states like California may work out well if they implement their own single payer systems, but smaller states that lack the populations will be hurting.

Their are two and only two basic principles that deliver affordable universal health care in modern economies. 1) You maximize leverage either by having a small number of highly regulated payers, or by having a single payer. 2) You lower individual costs by creating the largest possible pool of contributors.

Republican’s and many neoliberals don’t believe in government regulation, and they lack the economic sense to understand economies of scale. Contrary to “market” champion faith, profit motives and “innovation” do not conquer basic arithmetic.

We won’t ever have a system like the U.K.’s (it is a true, 100% socialized, gov-run system — worst thing imaginable, right?) but the guy’s perspective on it is interesting.

And when it comes to your fears of idealism, how hard it would be to run and, of course, the bank-breaking cost, bear in mind the U.K.’s been running their system since right after world war two (70+ years) and its costing $6,000 less per person per year than ours. They spend less than 9% of their GDP on it while we spend just under 18%.

If that’s your definition of “affordable” or “efficient,” or a gap you think would be closed by pushing the entire problem onto the states and making “able bodies” (Medicare and Medicaid recipients?) “get a job,” you need to do a quick calculation on what 18% of our GDP is and then take another look at what the dictionary says “affordable” and “efficient” mean.